Application of Evidence-Based Nursing Practice with · PDF fileUnderstanding the research ......

At the conclusion of this chapter, the learner will be able to

1. Synthesize key components from evidence-based nursing practice andresearch utilization to drive the provision of quality nursing care

2. Demonstrate proficiency in evidence-based practice using the princi-ples of the research process

➤ Evidence-based practice ➤ Research use

➤ Integrative reviews ➤ Systematic reviews

➤ Meta-analysis

Application ofEvidence-BasedNursing Practice

with Research

Sharon Cannon and Carol Boswell

Chapter Objectives

14Chapter

Key Terms

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© Jones and Bartlett Publishers. NOT FOR SALE OR DISTRIBUTION

Introduction

In Chapter 1, evidence-based practice (EBP) was defined as a research-based,decision-making process that is used to guide the delivery of holisticcare by nurses.The recent need for and acceptance of EBP is apparentin the literature. In a 2006 survey conducted by Sigma Theta TauInternational (STTI 2006), results suggested that a majority of thenurses needed evidence on a weekly basis to guide practice. About 90%of the participants indicated a moderate to high level of confidence inEBP. The results of this survey again support the premise that EBP is adriving force for the use of scientific data in the decision-makingprocess in the provision of nursing care.

Understanding the research process is the first step in using evi-dence in everyday nursing practice. Following initial historic back-ground regarding research in nursing, the other chapters of this bookhave focused on the research process. Examples of evidence-based prac-tice have been given to demonstrate how EBP is applied in specificcomponents of the research process.

Difficulty analyzing the evidence has been identified as a major ob-stacle to research use. The preceding chapters have provided informationto assist in the analysis of research findings in the application to nurs-ing care.This chapter is designed to “pull the pieces together” with apractical approach for research utilization in evidence-based nursingpractice.

Process for Evidence-Based Practice

318 | Chapter 14 Application of Evidence-Based Nursing Practice with Research

?Frequently, a laboring patient receives an epidural for painmanagement. A potential side effect of this procedure and thelaboring process is difficulty with urination. As a result, the pa-tient habitually receives catheterization to address this prob-lem. Depending on several factors, either a straight (in and out)catheter or a retention Foley catheter is used. Both methodsfor managing urinary retention include pros and cons.

• Based on the evidence, which way is best to manage thishealth challenge for the laboring client?

• List PICOT questions that could be generated from thisscenario.

• What ethical considerations would need to be addressedprior to a research study?

• How would you incorporate patient preferences into theevidence-based practice?

Think Outsidethe Box

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According to Myers and Meccariello (2006), “outdated practices arebarriers to decreased length of stay, favorable patient outcomes, andlowered costs” (p. 24). To move evidence-based nursing practice for-ward, a realistic approach for allowing bedside nurses to actively engagein the process must be determined and used. At each stage of provid-ing holistic care, nurses have to be confident in asking the questions andseeking the best practices to advance the provision of effective nursingcare. Omery and Williams (1999) set forth the initiative to ensure thatcareful and practical best evidence is used to propel health care deci-sions. Nurses must seek the best evidence to make sure that the care pro-vided represents the optimal health care available for the treatment planBy determining a functional method for documenting an EBP search,nurses can then gain confidence in conducting and implementing EBP.

The process for EBP determination is different from the process forresearch utilization. Research utilization is depicted in Chapter 13,which reflects how to complete an assessment of a single research re-port.The process for research utilization carefully examines a distinctstudy to determine the strengths and limitations assumed within thatone study. Research utilization becomes a key aspect within the over-all process of EBP, but it is only one piece. For a nurse to be able to ef-fectively utilize EBP, he or she does have to be able to conduct researchcritiques. Jolley (2002) supported this idea by emphasizing the needfor all nurses to be able to use research, but not everyone has to nec-essarily be able to conduct research. Bedside nurses need to understandhow to recognize the aspects within a research process that eitherstrengthen or limit the use of the results. By having this understandingabout the applicability of the results to practice, a nurse can then de-termine which studies can be used to sustain best practices in EBP. Asa result, nurses do need to appreciate the intricacies of the researchprocess. Bedside nurses should be able to identify the justifications thata researcher provides for selecting a specific method of sampling, datacollection, research design, and data analysis. If a researcher has a validexplanation for the choices employed within a study, the results can bevalued and incorporated into practice. Having begun the work withresearch critiques discussed in Chapter 13, the nurse can then move tothe next step of development to use those skills within the EBP process.

Melnyk and Fineout-Overholt (2005) delineated the process ofEBP as involving five critical steps.These five steps are

■ Raising the urgent clinical question using a format that pro-vides the key aspects of the issue

■ Assembling the most appropriate evidence that addresses theissue identified

■ Evaluating the evidence critically to determine the validity,relevance, and applicability

Process for Evidence-Based Practice | 319

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■ Assimilating the evidence into clinical practice■ Assessing the changes resulting from the use of the best

evidence

Each of these steps must be carefully completed to come to a determi-nation of best practices for a nursing setting. If an EBP process doesnot include all of the five steps, the result does not take into consider-ation all of the available evidence related to the clinical question.


?Over recent years, more and more parents are seeking alterna-tive birthing options. Some individuals elect to deliver at homedue to health care costs. Some make this decision from a de-sire to have a more natural birthing process. When complica-tions occur during the birthing process, the baby may have tobe admitted to an acute care setting. For newborn infants, thestandard initial treatment process includes erythromycin eyeointment, triple dye to the cord, and a vitamin K injection. If theparents voice concerns about these procedures, what stepswould a nurse need to take to provide evidence-based infor-mation concerning these procedures?



• What key words would be used for a literature search tolocate evidence related to this EBP question?

• What type of research project could be developed tofurther study this concern?



Although many models for EBP are currently being evaluated andmodified, Table 14-1 is provided as a quick and easy organizational de-sign. Within this format, the initial step is to refine the question con-fronting the nurse. Careful time and attention should be given toclarifying the five aspects driving the EBP question. As discussed pre-viously, the question should consider the following five aspects (PICOT):

■ P—Population of interest■ I—Intervention of interest■ C—Condition of interest■ O—Outcome of interest■ T—Time

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Tab

le 1

4-1

Form

at fo

r D

ocum

entin

g E

vid

ence

-Bas

ed P

ract

ice

Asp

ects

Qu

esti

on

to

be

con

sid

ered

wit

hin

th

e ev

iden

ce-b

ased

pra

ctic

e p

roce

ss:

P(P

opul

atio

n of

Inte

rest

): _

____

____

____

____

____

____

____

____

____

____

____

____

__

I (In

terv

entio

n of

Inte

rest

): _

____

____

____

____

____

____

____

____

____

____

____

____

__

C (

Com

paris

on o

f Int

eres

t): _

____

____

____

____

____

____

____

____

____

____

____

____

_

O (

Out

com

e of

Inte

rest

): _

____

____

____

____

____

____

____

____

____

____

____

____

___

T(T

ime)

: ___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

_

Wh

o

Wh

at

Wh

ere

Art

icle

sIn

volv

edO

ccu

rred

Co

mp

lete

dW

hen

W

hy

Ho

wC

on

sist

enci

esG

aps

Su

mm

ary

of

fin

din

gs:

Ap

plic

atio

n o

f fi

nd

ing

s to

evi

den

ce-b

ased

pra

ctic

e th

at v

alid

ates

/ch

ang

es p

olic

ies

and

pro

ced

ure

s:

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Each of these characteristics for the clinical questions was discussed inChapters 1 and 4. The development of a clear and concise clinical ques-tion is of paramount importance, because the question directs the en-tire process.

Once the question is determined, the nurse needs to work with thelibrarian to determine key words and/or expressions to use in con-ducting the literature review. Having appropriate terms to use withinthe various search engines helps to ensure that the resulting articlesprovide the structure for the analysis of the best practices. Melynk(2003) stated, “evidence-based practice is a problem-solving approachto clinical decision making that incorporates a search for the best andlatest evidence, clinical expertise, and assessment, and patient preferenceand values within a context of caring” (p. 6 of 7).

Malloch and Porter-O’Grady (2006) classified these investiga-tions of best practices as meta-analyses, systematic reviews, or integra-tive reviews. The combining of these different study types identifiedwithin the literature review and search engine inquiry provide thefoundation for determining whether there is a need to change prac-tice patterns. Meta-analysis incorporates a statistical technique to deter-mine the rigorousness of the findings from multiple studies on afocused question. A systematic review is the summarization of all evi-dence found correlated to an identifiable research or clinical issue em-ploying a rigorous format to ensure completeness of the assessment.An integrative review also summarizes prior research studies on a selectedtopic but, in addition, draws conclusions from the summary concern-ing the studies examined.

?Evidence-based practice should cause the nursing professionto question most of our normal activities. A simple skill such ascatheterizing an individual can result in an EBP question suchas: How much urine should a nurse drain off the bladder at onetime following a catheterization of a client?







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Process for Evidence-Based Practice | 323

The format provided in Table 14-1 allows for either a systematicreview or an integrative review. Once the PICOT question has been de-termined and the literature review has been completed, each of theidentified articles/studies is carefully assessed. For each article, the whoinvolved (sample), what occurred (research design), where completed,when,why,and how (statistical/data analysis) are determined and documented.Asthese aspects of a research critique are completed on the different stud-ies, consistencies and/or gaps within the different studies begin tosurface.The identification of consistencies within the different studiesprovides support for potential changes in practice or confirmation ofbest practices currently being used. The detection of gaps within thestudies presents the need for further and/or more in-depth research en-deavors on the topic under consideration.The idea of identifying con-sistencies and gaps within the different articles/research reports isrelated to the concept of similarities and the omissions that may be pres-ent. Associations established from the results of the various studiesneed to be collected to add strength to the rationale for making anychanges in policies and procedures related to the selected clinical ques-tion. If several studies all reflect the equivalent results, then nursingpractice should embrace the behavior as supported by evidence. On theother hand, if multiple studies all reflect a gap in knowledge relatedto the selected clinical question, then further research should be di-rected toward the identified segment of nursing practice. Accordingto Pravikoff,Tanner, and Pierce (2005), “the finding that a lack of valuefor research in practice was the most frequently selected barrier to the useof research in practice is of greatest concern” (p. 13 of 17). Whenpracticing nurses cannot or do not use research results to strengthenand sustain holistic nursing practice, the implementation of EBP atthe bedside becomes incomplete.

After completing the grid portion of Table 14-1, time must begiven to summarizing the findings. The nurse should pay careful atten-tion to and critically consider the meaning ensuing from the consis-tencies and gaps identified. This painstaking contemplation of thediscovered omissions and similarities focuses the next steps within theprocess. By taking the time and energy to summarize and synthesizethe information collected, the nurse becomes well versed in the cur-rent state of the clinical problem. Obtaining this clearer viewpoint re-lated to the clinical problem allows the nurse to make an informeddecision as to what is needed next in this challenge

The final section of this table relates to the application aspect. Aftercompleting each of these prior steps, the nurse has a base on which tomake recommendations for maintaining or changing a policy or pro-cedure.The time taken to complete this exercise allows for any recom-mendations to be based on sound, factual data.The suggestions can thenbe effectively supported by a wealth of tested research endeavors.

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Conclusion

Yoder (2005) stated, “both EBP and QI initiatives require ongoing eval-uation of the practice environment, the appropriate use of data collec-tion and evaluation, and the dissemination of the information learnedthrough excellent communication process both from the top downand the bottom up” (p. 3 of 3). Resources are available to aid the nurseto strengthen EBP foundations and activities (see Table 14-2). The cur-


?Frequently, an insulin drip protocol will seek to maintain aserum blood sugar result between 70 to 110 mg/dl. At onehealth care agency, a pilot research project revealed a meanblood sugar for patients dismissed from a cardiac intensivecare unit after three months was 148. The nurses questionedthe protocol ranges as a result of this pilot study result.







Table 14-2

Suggested Resources to Support the Retrieval and Appraisal of Evidence

• Oncology Nursing Society (ONS) EBP Online Resource Center “Evidence Search” section: http://onsopcontent.ons.org/toolkits/ebp/process_model/evidence_search.htm

• National Library of Medicine Web site, which allows free searches of MEDLINE through PubMed:www.ncbi.nlm.nih.gov/entrez/query.fcgi

• National Guidelines Clearinghouse: www.guideline.gov

• National Comprehensive Cancer Network: www.nccn.org

• Agency for Healthcare Research and Quality: www.ahrq.gov

• Cochrane Database of Systematic Reviews: www.updates-software.com/conchrane/abstract.htm

• University of Alberta – EB Medicine Tool Kit: www.ualberta.ca/ebm/ebm.htm

• RNAO Best Practice Guidelines: www.rnao.org

• Centre for Evidence-Based Nursing (York, UK):www.york.ac.uk/healthsciences/centres/evidence/cebn.htm

• Joanna Briggs Institute: www.joannabriggs.edu.au

• ScHARR Netting the Evidence: www.shef.ac.uk/scharr/ir/netting

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rent health care community requires nurses and other health careproviders to be diligent in the determination and provision of holistichealth care. The different treatments and plans of care put forth forclients must be based on factual, tested data. Each nurse must take re-sponsibility for ensuring that the care provided is based on firm, accu-rate research data. This research data is then used to provideindividualized health care to clients based on factual data, patient pref-erences, and nursing expertise.

Conclusion | 325

?Gather at least three of your peers and form a journal club.Select a topic of your choice and identify a PICOT question.Conduct an integrative review for the selected topic. Whatconclusion can you draw from the review? How will thischange your practice?


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Summary Points

1. Evidence-based practice (EBP) was defined as a research-based, decision-making process used to guide the delivery of holistic care by nurses.

2. Understanding the research process is the first step in using evidence ineveryday nursing practice.

3. To move evidence-based nursing practice forward, a realistic approach forallowing bedside nurses to actively engage in the process must be deter-mined and used.

4. The process for research use carefully examines a distinct study to deter-mine the strengths and limitations assumed within that one study.

5. By having an understanding of the applicability of the results to practice,a nurse can then determine which studies can be used to sustain bestpractices in EBP.

6. The development of a clear and concise clinical question is of paramountimportance, because the question directs the entire process.

7. Meta-analysis incorporates a statistical technique to determine the rigor-ousness of the findings from multiple studies on a focused question.

8. A systematic review is the summarization of all evidence found correlatedto an identifiable research or clinical issue employing a rigorous formatto ensure completeness of the assessment.

9. An integrative review also summaries prior research studies on a selectedtopic but, in addition, draws conclusions from the summary concerningthe studies examined.

10. For each article, the who involved (sample), what occurred (research design),where completed,when,why, and how (statistical/data analysis) are determinedand documented.

11. The identification of consistencies within the different studies providessupport for potential changes in practice or confirmation of best practicescurrently being used.

12. The detection of gaps within the studies presents the need for furtherand/or more in-depth research endeavors on the topic under consideration.

13. Obtaining this clearer viewpoint related to the clinical problem allows thenurse to make an informed decision as to what is needed next in thischallenge.


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Red Flags | 327

RED FLAGS

• Research utilization and evidence-based practice are not one and the same.

• The recommendation for changing nursing practice must be based on sound

evidence not a single study.

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A Hispanic woman presents to the Emergency Room complaining of epigas-tric pain in atypical form, nausea, diaphoretic, and complaining of neck pain.The initial assessment reveals a 60-year-old, Hispanic female with a history ofdiabetes and hypertension. She has a granddaughter attending nursing schoolat the local community college.The client reports being a smoker with a fam-ily history of cardiac problems. She is 5 feet 3 inches tall and weighs 185pounds. She is a homemaker with no outside employment. For the most part,she reports a sedentary life style and denies alcohol consumption. The ERphysician orders an EKG and cardiac panel to rule out an acute myocardial in-farction. Other tests ordered include a chest X-ray, urinalysis, and standardchemistry (CBC, troponins, creatinine protein). The tests revealed elevatedtroponin and EKG changes with an elevation in the ST segment.The client isdiagnosed with a full-blown myocardial infarction.The ER physician mobilizesthe cath lab team and orders a cardiology consultation. The client is trans-ported to the cath lab for an angiogram, which reveals two blocked cardiac ves-sels. After a double angioplasty is performed, the client is transferred to theCardiac Care Unit. After she arrives in the unit, the nursing staff assessed theclient and determines that the angioplasty versus manual compression wascompleted with Perclose. The use of this closure for angioplasty has been asource of discussion in the CCU. As a result of this case and others, the nurs-ing staff elects to engage in an evidence-based practice activity to determineif the policies and procedures currently used on the unit reflect the best prac-tices for this type of client and medical treatment plan.The following PICOTquestion was identified (see Table 14-3). The EBP process was initiated.

As can be seen from the case study analysis, there are gaps in the literature inthe lack of actual research projects on the use of Perclose versus manual pres-sure.All of the literature reviewed were case studies with reference to recom-mendations from the manufacturer. If the nurses wished to continue furtherexploring Perclose, they could use the Gap Table (Table 5.4) in Chapter 5.However, the case study illustrates how EBP and research can lead to specificactions to improve nursing care.Thus, patient outcomes can be improved.

Case Scenario

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References

Tab

le 1

4-3

Form

at fo

r D

ocum

entin

g E

vid

ence

-bas

ed P

ract

ice

Asp

ects

Qu

esti

on

to

co

nsi

der

wit

hin

th

e ev

iden

ce-b

ased

pra

ctic

e p

roce

ss:

P(P

opul

atio

n of

Inte

rest

): _

___

His

pani

c ad

ult 5

0 ye

ars

or o

lder

I (In

terv

entio

n of

Inte

rest

): _

___

Per

clos

e us

age

C (

Com

paris

on o

f Int

eres

t): _

___

Man

ual p

ress

ure

O (

Out

com

e of

Inte

rest

): _

___

decr

ease

d le

ngth

of s

tay,

dec

reas

ed h

emat

oma,

dec

reas

ed d

isco

mfo

rt, d

ecre

ased

infe

ctio

n ra

te

T(T

ime)

: ___

_ w

ithin

2 w

eeks

from

dis

char

ge

Wh

o

Wh

at

Wh

ere

Art

icle

sIn

volv

edO

ccu

rred

Co

mp

lete

dW

hen

W

hy

Ho

wC

on

sist

enci

esG

aps

Gea

ry, L

ande

rs, F

iore

, &R

iggs

. (20

02).

Man

agem

ent o

f inf

ecte

dfe

mor

al c

losu

re d

evic

es,

Car

diov

ascu

lar

Sur

gery

,10

(2),

161

–163

.

Hec

k, M

uldo

wne

y, &

McP

hers

on. (

2002

).In

fect

ious

com

plic

atio

nsof

Per

clos

e fo

r cl

osur

e of

fem

oral

art

ery

punc

ture

s,JV

IR,4

27–4

31.

Joha

nnin

g, F

ranl

in,

Elm

ore,

& H

an. (

2001

).F

emor

al a

rter

y in

fect

ions

asso

ciat

ed w

ith p

ercu

ta-

neou

s ar

teria

l clo

sure

de-

vice

s, J

ourn

al o

f Vas

cula

rS

urge

ry, 3

4(6)

, 983

–985

.

Infe

ctio

n

Infe

ctio

n

Infe

ctio

ns

2002

2002

2001

Cas

est

udie

s

Cas

est

udie

s

Cas

est

udie

s

4 m

ales

, 1 fe

mal

eag

e ra

nge

63–7

3

2 fe

mal

es, 1

mal

e,ag

e ra

nge

40–7

6

2 m

ales

, age

rang

e 50

–56

NY,

Acu

te c

are

unit,

out

patie

nt,

gene

ral h

ospi

tal

Thr

ee d

iffer

ent

inst

itutio

ns

Eas

tern

Sta

te

Exa

min

ed P

ercl

ose,

no

in-

dica

tion

of p

roph

ylac

tic a

nti-

biot

ic u

se, s

taph

yloc

occu

sin

fect

ions

Rep

ort o

f cas

es, 3

day

spo

st o

p.

Add

to d

ata,

sta

phyl

ococ

cal

arte

rial i

nfec

tion,

MR

SA

,bl

ood

seru

m a

t site

ser

ved

as b

acte

rial g

row

th m

ediu

m

All

had

infe

ctio

ns, s

utur

epl

acem

ent,

antib

iotic

s

2 ha

d st

aphy

loco

ccal

,on

e fr

om b

acte

rial,

con-

cern

s ab

out s

utur

epl

acem

ent

Sut

ure

plac

emen

t, pr

e-pr

oced

ure

antib

iotic

s

Littl

e re

sear

ch,

reco

mm

enda

-tio

ns c

ame

from

man

ufac

ture

r,no

indi

catio

n of

ethn

ic o

rigin

Ref

ers

to p

ub-

lishe

d tr

ials

Ref

ers

toM

AU

DE

, no

time

desi

gnat

ion

on th

ese

case

sas

to h

ow lo

ngbe

fore

iden

tific

a-tio

n of

infe

ctio

n

cont

inue

s

40403_CH14_317_334.qxd 12/27/06 10:59 AM Page 329


Tab

le 1

4-3

co

nti

nu

ed

Form

at fo

r D

ocum

entin

g E

vid

ence

-bas

ed P

ract

ice

Asp

ects

Wh

o

Wh

at

Wh

ere

Art

icle

sIn

volv

edO

ccu

rred

Co

mp

lete

dW

hen

W

hy

Ho

wC

on

sist

enci

esG

aps

Ties

enha

usen

, Tom

ka,

Allm

ayer

, Bau

man

n,H

essi

nger

, Por

tuga

ller,

&M

ahle

r (2

004)

. Fem

oral

arte

ry in

fect

ion

asso

ciat

edw

ith a

per

cuta

neou

s ar

te-

rial s

utur

e de

vice

, VA

SA

,33

,83–

85.

Infe

ctio

nre

sulti

ng in

sept

ic d

eath

2004

Cas

est

udie

s77

-yea

r-ol

d m

ale

Aus

tria

A

dd to

dat

a, in

fect

ion

iden

-tif

ied

4 w

eeks

pos

t hos

pita

l-iz

atio

n, s

een

in E

R p

rior

tofin

al a

dmis

sion

to h

ospi

tal

with

sep

sis,

Per

clos

e ca

r-rie

s ris

k of

fem

oral

art

ery

infe

ctio

ns

Ste

rile

field

mus

t be

mai

ntai

ned,

sut

ure

plac

emen

t

Ref

ers

to r

e-se

arch

, not

of

His

pani

c or

igin

Su

mm

ary

of

fin

din

gs:

Per

clos

e ca

n re

duce

leng

th o

f sta

y; T

o im

prov

e ou

tcom

es –

pro

per

use

of P

ercl

ose

and

cons

ider

atio

n of

pro

phyl

actic

ant

ibio

tic th

erap

y sh

ould

be

utili

zed

in c

onju

nctio

n w

ith th

e us

eof

Per

clos

e; A

ll of

the

revi

ewed

art

icle

s w

ere

case

stu

dies

; No

quan

titat

ive

rese

arch

was

foun

d; N

o nu

rse-

dire

cted

res

earc

h w

as lo

cate

d, L

engt

h of

tim

e be

fore

infe

ctio

ns id

entif

ied

rang

ed fr

om 3

day

s to

4 w

eeks

; Ste

rile

tech

niqu

e du

ring

proc

edur

e is

par

amou

nt.

Ap

plic

atio

n o

f fi

nd

ing

s to

evi

den

ce-b

ased

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Suggested Readings | 331

Suggested Readings

Suggested Readings | 331

Coopey, M., & Clancy, C. M. (2006, July/September). Translating researchinto evidence-based nursing practice and evaluating effectiveness. Journalof Nursing Care Quality, 21(3), 195–202.

Marchiondo, K. (2006, January/February). Planning and implementing anevidence-based project. Nurse Educator, 31(1), 4–6.

Newhouse, R. P. (2006, July/August). Examining the support for evidence-based nursing practice. Journal of Nursing Administration, 36(7-8),337–340.

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332 | Chapter 14 Application of Evidence-based Nursing Practice with Research

References

Jolley, S. (2002). Raising research awareness: A strategy for nurses. Nursing Standard,16(33), 33–39.

Malloch, K., & Porter-O’Grady, T. (2006). Introduction to evidence-based practice in nursing andhealth care. Boston: Jones and Bartlett Publishers.

Melnyk, B. M. (2003). Finding and appraising systematic reviews of clinical interven-tions: Critical skills for evidence-based practice. Journal of Pediatric Nursing, 29(2),125, 147–149.

Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare:A guide to best practice. Philadelphia: Lippincott Williams & Wilkins.

Myers, G., & Meccariello, M. (2006). From pet rock to rock-solid: Implementing unit-based research. Nursing Management, 37, 24–29.

Omery, A., & Williams, R. P. (1999). An appraisal of research utilization across theUnited States. Journal of Nursing Administration, 29(12), 50–56.

Pravikoff, D. S,Tanner,A. B., & Pierce, S.T. (2005). Readiness of U.S. nurses for evidence-based practice. American Journal of Nursing, 105(9), 40–51.

Sigma Theta Tau International. (2006). Results of EBN survey. Retrieved from an e-maildated June 12, 2006 from Sigma Theta Tau International Honor Society ofNursing. NurseAdvanceTM: Knowledge Solutions.

Yoder, L. (2005). Evidence-based practice: The time is now! Medsurg Nursing, 14(2),91–92.

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Critical Thinking Exercise | 333

Critical Thinking Exercise

Multiple ideas related to potential clinical questions are provided foryour consideration. Select a situation to use in working through theprocess reflected in Table 14-1.The situations are presented in a briefmanner.Take the idea and develop the PICOT question to best meet theneeds at a selected health care agency of your choice. These ideas areprovided to stimulate thought and ideas.

■ A possible clinical question relates to whether a relationship be-tween adequate pain control and length of stay in a communityhospital setting could be determined.

■ Another clinical situation for investigation involves the determina-tion of any relationship between glucose control during the opera-tive period and length of stay in an acute care setting.

■ An alternative clinical circumstance relates to the effect of a one-on-one diabetic education course on the patient’s HbA1C.

■ In the occurrence of a medication error, the value of full disclosureto patients and/or family to build trust and restore confidence asopposed to nondisclosure, with a look at the impact on perceivedquality of care, could be investigated.

■ An additional idea involves determining whether the length of timeand frequency of visits to patient’s rooms by nursing staff affectsthe number of calls and the perception of quality of care by thepatient and/or family members.

■ Maternal/child nurses understand that certain treatments (prophy-laxis eye treatments, vitamin K injections, PKU tests) are providedfor all newborn children. What happens to children born outside ofan acute care setting (e.g., home births)? What rationales do wehave to support these treatments?

■ Childhood immunization is a state-directed process for all school-age children. Certain immunizations (MMR, polio, DPT) are desig-nated at key times prior to and during the school age years. Sowhat is happening with the growing number of home-schooledchildren? Are they getting the immunizations? What happenswhen these children come into acute care settings without havingreceived the expected childhood immunization series?

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